Anxiety Disorders

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					 Anxiety Disorders

Samantha Meltzer-Brody, M.D., M.P.H.
        Assistant Professor
   UNC Department of Psychiatry
   Nervousness and fear are common
    human emotions.
   Adaptive at lower levels; disabling at
    high levels.
   Physicians must recognize the
    difference between pathological anxiety
    and anxiety as a normal or adaptive
Features of Pathologic Anxiety
   Autonomy: no or minimal
    environmental trigger
   Intensity: exceeds patient’s capacity to
    bear the discomfort
   Duration: symptoms are persistent
   Behavior: anxiety impairs coping and
    results in disabling behaviors
Definition of Anxiety
   Diffuse, unpleasant, vague sense of
   Often accompanied by autonomic symptoms
    such as headache, perspiration, heart
    palpitations, chest tightness, stomach
    discomfort and restlessness
   Presentation depends on perception of stress,
    personal resources, psychological defenses,
    and coping mechanisms
   Neurophysiology
       Central noradrenergic systems– in particular, the
        locus coeruleus is the major source of adrenergic
       GABA neurons from the limbic system
       Serotoninergic systems and neuropeptides
   Cognitive-Behavioral Formulations
   Developmental (Psychodynamic)
Anxiety Disorders
   The most prevalent psychiatric disorders
   One-quarter of the U.S. population
    experiences pathologic anxiety in their
   Presenting problem for 11% of patients
    visiting primary care physicians
   90% of patients with anxiety present with
    somatic complaints
Common Medical Conditions
Associated with Anxiety Disorders
   Endocrine: thyroid      Hypoxia: CHF,
    dysfunction, hyper       angina, anemia,
    adrenalism               COPD
   Drug Intoxication:      Metabolic: acidosis,
    caffeine, cocaine        hyperthermia
   Drug Withdrawal:        Neurological:
    alcohol, narcotics       seizures, vestibular
Major Anxiety Disorders
   Panic Disorder
   Generalized Anxiety Disorder
   Post Traumatic Stress Disorder
   Social Phobia
   Specific Phobia
   Obsessive Compulsive Disorder (OCD)
   Substance Induced Anxiety Disorder
Panic Attack
   Discrete episodes of intense anxiety
   Sudden onset
   Peak within 10 minutes
   Associated with at least 4 of the 13
    other somatic or cognitive symptoms of
    autonomic arousal
Panic Attack Symptoms
   Cardiac: palpitations, tachycardia, chest
    pain or discomfort
   Pulmonary: shortness of breath, a
    feeling of choking
   GI: nausea or abdominal distress
   Neurological: trembling and shaking,
    dizziness, lightheadedness or faintness,
Panic Attack Symptoms
   Autonomic Arousal: sweating, chills or
    hot flashes
   Psychological:
       Derealization (feeling of unreality)
       Depersonalization (feeling detached from
       Fear of losing control or going crazy
       Fear of dying
Panic Disorder
   A syndrome characterized by recurrent
    unexpected panic attacks (at least 4 in
    one month)
   Attacks are followed for at least one
    month with:
       Concern about having another attack
       Worry about implications of the attack
       Behavior changes because of the attacks
   Complication of panic disorder
   Means “ fear of the market”
   Anxiety or avoidance of places or
    situations from which escape might be
    difficult, embarrassing, or help may be
   Restricts daily activities
   Agoraphobia
       The patient may avoid crowds, restaurants,
        highways, bridges, movie theaters etc.
       In its most severe form, the patient may
        become dependent on companions to face
        situations outside the home.
       Some individuals become homebound.
Epidemiology of Panic Disorder
   Panic disorder has a lifetime prevalence
    of 1.5-3.5%
   2:1 female/male ratio
   ? Of true gender difference versus men
    tend to self-medicate with alcohol and
    are less likely to seek treatment.
   Onset is late teens through third decade
    of life.
Differential Diagnosis of Panic
   Not due to another anxiety disorder
   Not due to effects of a general medical
       Cardiovascular disease
       Pulmonary disease
       Neurological disease
       Endocrine disease
       Drug intoxication or withdrawal
       Other (lupus, infections, heavy metal poisoning,
        uremia, temporal arteritis)
Panic Disorder: Costs
   200,000 normal coronary angiograms/yr in
    the U.S. at a cost of 600 million dollars: 1/3
    of these patients have panic disorder
   ½ of patients referred for non-invasive
    testing for atypical chest pain and who have
    normal tests have panic disorder
   1/3 patients undergoing work-up for
    vestibular disorder with c/o dizziness have
    panic disorder
     Panic Disorder: Comorbidity
   Panic disorder patients have an increased
    personal and family history of other
    anxiety, mood and substance abuse
   Major depression is a co-morbid diagnosis
    in 1/3 of cases presenting for treatment
   Untreated patients have high risk of suicide
Panic Disorder: Treatment
   About 80% of patients will respond to
   Antidepressant medications are
       Serotonin reuptake inhibitors (SSRI) are
        first line therapy
       Tricyclic antidepressants (TCA) and
        monoamine oxidase inhibitors (MAOI’s) are
        also used.
Panic Disorder: Treatment
   Sedative-Hypnotics: benzodiazepines
    are ideally used in the short term before
    an antidepressant has had time to work
   Cognitive Behavioral Therapy (CBT):
    helps patients overcome a learned
    pattern of catastrophically
    misinterpreting the physical symptoms
    associated with panic attacks.
Generalized Anxiety Disorder
   Patients with GAD suffer from severe
    worry or anxiety that is out of
    proportion to situational factors.
   Must last most days for at least 6
   Described as “worriers” or “nervous”
   Symptoms include:
       Muscle tension
       Restlessness
       Insomnia
       Difficulty concentrating
       Easy fatigability
       Irritability
       Persistent anxiety (rather than discrete
        panic attacks)
GAD Diagnostic Criteria
   Excessive anxiety and worry that occurs
    more days than not for 6 months
   Difficult to control the worry
   3 out of 6 symptoms
   Anxiety caused significant distress or
    impairment in function
   Not attributed to another organic cause
GAD Epidemiology
   5% prevalence in community samples
   2:1 female/male ratio
   Age of onset is frequently in childhood
    or adolescence
   Chronic but fluctuating course of illness
    (worsened during stressful periods)
GAD Treatment
   Cognitive Behavioral Therapy
   Other Psychotherapies
   Pharmacotherapy
       Antidepressants
       Benzodiazepines
       Buspirone
Post Traumatic Stress Disorder
   Patients with PTSD have experienced a
    trauma and develop disabling
    symptoms in response to the event.
   Symptoms usually begin within 3
    months of the trauma
   Syndrome can occur at any age
Definition of Trauma
   The person experienced, witnessed or
    learned of an event that involved actual
    or threatened death, serious injury, or
    threat of harm to self or others

   The person’s response involved intense
    fear, helplessness or horror
Types of Trauma
   Sexual abuse              Being diagnosed with a
   Rape                       life threatening illness
   Physical abuse            Sudden unexpected
   Severe motor vehicle       death of family/friend
    accidents                 Witnessing violence
   Robbery/mugging            (including domestic
   Terrorist attack           violence)
   Combat veteran            Learning one’s child has
   Natural disasters          life threatening illness
Diagnosis of PTSD
   Symptoms must be > one month
    duration and include:

     Re-experiencing symptoms
     Avoidance symptoms

     Emotional numbing

     Hyperarousal symptoms
Re-experiencing Symptoms
   There are recurrent, intrusive thoughts
    of the event (can’t not think about it)
   Dreams (nightmares) about the event
   Acting or feeling the event is recurring,
    or sense of living the event (flashbacks)
   Psychological or Physiological Distress
    upon exposure to reminders or cues of
    the event.
   Avoid thoughts, feelings, places or people
    that arouse memories of the event
   Being unable to recall important parts of the
   Decrease interest in activities
   Feeling detached or estranged from others
   Decreased range of affect
   Sense of foreshortened future
Hyperarousal Symptoms
   Patient experiences at least two of the
       Insomnia (falling or staying asleep)
       Irritability or outbursts of anger
       Decreased concentration
       Hypervigilance
       Increased/exaggerated startle response
Epidemiology of PTSD
   Prevalence is 1% in the general
    population, and can be as high as 25%
    in those who have experienced trauma
   In combat veterans, prevalence is 20%
   Very high prevalence in women who are
    victims of sexual trauma
PTSD Costs
   Patients with PTSD are frequent users
    of the health care system
   Patients usually present to primary care
    physicians with somatic complaints
   After panic disorder, PTSD is the most
    costly anxiety disorder
PTSD Treatment
   Psychotherapies
       Exposure-based cognitive behavioral therapy
       Psychotherapy aimed at survivor anger, guilt and
        helplessness (victimization)
   Pharmacological treatment targets the
    reduction of prominent symptoms
       SSRI’s are first line therapy
       Atypical antipsychotics are being increasingly used
Social Phobia
   Fear of being exposed to public scrutiny
   Fear of behaving in a way which will be
    humiliating or embarrassing
   Symptomatic resemblance to panic
    disorder with anticipatory anxiety
    (person may be anxious/worrying far in
    advance of the event)
   Extensive phobic avoidance
Social Phobia
   Distinction: anxiety only occurs when
    the patient is subject to the scrutiny of
    others (public speaking, oral exam,
    eating in the cafeteria)
   Phobic stimulus is avoided or endured
    with intense anxiety
   Fear and avoidant behaviors interfere
    with person’s normal routine or cause
    marked distress
Epidemiology: Social Phobia
   Prevalence rates vary depending on
    study; overall range is 3 –13% of the
   Onset in adolescence
   Prevalence greater in females, but
    greater for males in clinical samples
   Frequent comorbidity with depression
    and substance abuse
Social Phobia: Treatment
   Antidepressants, SSRI’s and MAOI’s
   High potency benzodiazepines
   Low doses of beta blockers are helpful
    for public speaking (if only an
    occasional event); this alleviates the
    autonomic symptoms
   Psychotherapy-cognitive restructuring
Specific Phobia
   Marked and persistent fear that is
    excessive and unreasonable of a
    specific object or situation
   Exposure to the phobic stimulus will
    provoke an anxiety response
Phobia Subtypes
   Animals or insects
   Natural environment– storms, water, heights
   Blood, injury, injection, medical procedure
   Situational flying, driving, enclosed places
   Having a phobia of a specific subtype
    increased the chances of having another
    phobia within that subtype
Epidemiology of Specific Phobias
   Lifetime prevalence is 10% of the
   Age of onset varies with subtype
       Childhood onset for phobias of animals,
        natural environments blood and injections
       Bimodal distribution (childhood and mid-
        twenties for situational phobias
Specific Phobia Treatments
   Flooding-exposing the person to the
    feared stimulus
   Exposure therapy works to desensitize
    the patient using a series of gradual,
    self-paced exposures to the phobic
    stimulus; uses relaxation, hypnosis,
    breathing control and other cognitive
   Benzodiazepines or Beta blockers are
    useful acutely
Specific Phobia: Treatment
   Example: Fear of Flying
       Visualize a plane. Look at a plane in the
        sky. Drive by an airport. Go to a museum
        that has planes. Same museum—visualize
        going inside. Go inside. Go to airport and
        watch planes take off and land. Visualize
        yourself on a plane flying. Omnimax
        theater experience. The real thing.
Obsessive Compulsive
Disorder (OCD)
   Obsessions: recurrent, intrusive,
    unwanted thoughts (i.e. fear of
   Compulsions: behaviors or rituals aimed
    at reducing distress or preventing a
    dreaded event (i.e. compulsive
OCD Symptoms
   Recurrent obsessions and/or
    compulsions are severe enough to
    consume more than one hour/day
   Person recognizes the obsession as a
    “product of his/her own mind”, rather
    than imposed from the outside, and
    that they are unreasonable or excessive
OCD Symptoms
   The obsessions are “ego-dystonic” (not
    enjoyable for the ego), as opposed to
    “ego-syntonic” (the ego likes it)
Common Obsessions
   Contamination
   Repeated doubts
   Order
   Aggressive or horrific images
   Sexual/pornographic imagery
   Scrupulosity
Obsessions and Common
Compulsive Responses
   Contamination: cleaning, hand washing,
   Repeated doubts: checking, requesting or
    demanding reassurances from others,
   Order: checking, rituals, counting
   Aggressive or horrific images, checking,
    prayers, rituals
   Sexual/Pornographic imagery: prayer/rituals
Epidemiology of OCD
   Lifetime prevalence is 2-3% in the
    general population
   Mean age of onset is mid-twenties,
    although men may develop symptoms
   Less than 5% of patients develop
    disease after age of 35 years
   Chronic course, stress can exacerbate
OCD Treatment
   Serotonin reuptake inhibitors
   Clomipramine, a serotonergic tricyclic
   Psychotherapy: exposure and response
OCD is not OCPD
   Obsessive-Compulsive Disorder is
    different from obsessive compulsive
    personality disorder (OCPD)
   OCPD: a pervasive pattern of
    preoccupation with orderliness,
    perfectionism and control that begins
    by early adulthood
Substance Induced Anxiety
   Prominent symptoms of anxiety that are
    judged to be the direct physiological
    consequence of a drug or abuse, a
    medication or toxin exposure
Summary and Review of
Anxiety Disorders
Panic Attacks and Panic Disorder
   Panic Attacks
   Agoraphobia without a history of panic
   Panic Disorder without agoraphobia
   Panic Disorder with agoraphobia
Generalized Anxiety Disorder
   Characterized by at least 6 months of
    persistent and excessive anxiety and
Post Traumatic Stress Disorder
   Characterized by the re-experiencing of an
    extremely traumatic event accompanied by
    symptoms of increased arousal and by
    avoidance of stimuli associated with the
   Symptoms present for at least one month
   If event just occurred and/or symptoms
    present for less than one month, a diagnosis
    of Acute Stress Disorder is given
Social Phobia
   Clinically significant anxiety provoked by
    exposure to certain types of social or
    performance situations, often leading to
    avoidance behavior
Specific Phobia
   Clinically significant anxiety provoked by
    exposure to a specific feared object or
    situation, often leading to avoidance
Obsessive Compulsive
   Characterized by obsessions that cause
    marked anxiety or distress and/or
    compulsions that serve to neutralize
   Substance Induced Anxiety Disorder

   Anxiety Disorder not otherwise specified
Anxiety Disorder Association
of American (ADAA)
   The ADAA brings together professionals
    from many disciplines including
    psychiatrists, psychologists, social workers,
    physicians, nurses, etc. Through networks,
    the ADAA increases awareness about
    anxiety disorders, provides education
    resources, offers access to care, and
    supports research.

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